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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates advanced knowledge of Medicare Part D regulations and compliance, with strong skills in managing and reconciling pharmacy claims and data analysis. Proficient in navigating EMR systems and utilizing advanced Excel for reporting and data management.
Highest-signal resume keywords
Medicare Part D ComplianceEMR Data InterpretationAdvanced Excel SkillsPharmacy Claims ManagementAttention to Detail
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Pharmacy Claims ManagementMedicare Part D RegulationsData ReconciliationPDE SubmissionsEMR NavigationExcel FormulasData AnalysisMedication KnowledgeReport GenerationProblem Solving
Soft Skills
Attention to DetailCommunication SkillsOrganizational SkillsIndependent WorkPrioritization
Tools & Technologies
EMR SystemsExcelWord ProcessorsDatabase SoftwarePBM Systems
Certifications & Qualifications
Background Screening (Florida Care Provider)
Industry Keywords
MedicareMedicaidPACE ProgramsPharmacy Benefit ManagementHealthcare Compliance
About the role
Key responsibilities & impact- Manage and reconcile Part A claims and stays
- Perform Part D compliance tasks, including B vs D, ESRD, and Medical Necessity
- Manage participant plan enrollment status with the pharmacy and PBM
- Ensure claims are billed to Part D appropriately based on CMS regulations and EMR documentation
- Download and review weekly, monthly, and quarterly Part D and PBM reports and take necessary actions
- Download and review CMS reports and take necessary actions
- Reconcile rejected claims and submission concerns with pharmacies and the PBM
- Assist in reconciling PDE data
- Summarize and report PDE progress
- Prepare, submit, and analyze PDE submissions to CMS
- Stay current on pharmacological updates and Medicare Part D guidelines
- Coordinate with Medicare and Medicaid specialists as needed
- Work with finance and billing specialists on bill resolution
- Manage provider credentials for the PBM and contracted pharmacy
- Perform other duties as needed
- Work independently in a work-from-home position while managing large volumes of data
Requirements
What you’ll need- 3+ years working with medical and/or pharmacy claims
- Current advanced knowledge of medication names, dosages, indications, and routes of administration
- Experience and comfort navigating EMR and interpreting EMR data
- Advanced Excel skills for managing large volumes of data, including formulas, pivots, and reports
- Ability to solve problems under pressure
- Strong attention to detail and ability to prioritize workload
- Comfortable working independently
- Excellent communication and organization skills
- Strong computer skills, including word processors, spreadsheets, and database software
- Associate’s degree or formal training beyond high school in lieu of an Associate’s degree
- Florida applicants require background screening through the Florida Care Provider Background Screening Clearinghouse
- Preferred: experience with EPIC EMR
- Preferred: experience managing patient plan eligibility
- Preferred: experience in a PACE or similar healthcare program
- Preferred: knowledge of Medicare Part D regulations and compliance requirements
- Bachelor’s degree preferred
Benefits
Comp & perks- Medical, dental, and vision insurance
- Short- and long-term disability insurance
- Life insurance and AD&D
- Supplemental life insurance
- Flexible spending accounts
- 401(k) savings plan with company match
- Paid time off
- Company-paid holidays
- Equal opportunity and affirmative action workplace
- Diverse and inclusive workplace
- Patient-centered care model
- Work-from-home position